ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. A nurse is assessing a client who has schizophrenia and is experiencing negative symptoms. Which of the following findings should the nurse expect?
- A. Hallucinations
- B. Delusions
- C. Flat affect
- D. Paranoia
Correct answer: C
Rationale: The correct answer is C: Flat affect. Negative symptoms of schizophrenia involve deficits in normal emotional responses or other thought processes. These symptoms include a flat affect (reduced emotional expression), social withdrawal, and avolition (lack of motivation). Hallucinations and delusions are characteristic of positive symptoms, which involve the presence of abnormal behaviors or experiences. Paranoia is more associated with delusions rather than negative symptoms.
2. The client with deep vein thrombosis (DVT) is receiving anticoagulant therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the therapy?
- A. Complete blood count (CBC)
- B. Activated partial thromboplastin time (aPTT)
- C. Serum electrolytes
- D. Liver function tests
Correct answer: B
Rationale: Activated partial thromboplastin time (aPTT) is the correct laboratory test to monitor the effectiveness of anticoagulant therapy, especially with heparin. A prolonged aPTT indicates effective anticoagulation, reducing the risk of further clot formation in the client with deep vein thrombosis (DVT). The other options, such as complete blood count (CBC), serum electrolytes, and liver function tests, do not directly assess the therapeutic effectiveness of anticoagulant therapy. Therefore, the correct answer is B.
3. In an emergency mental health facility, a nurse is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission?
- A. A client with schizophrenia who has delusions of grandeur
- B. A client with manifestations of depression who attempted suicide a year ago
- C. A client with borderline personality disorder who assaulted a homeless man with a metal rod
- D. A client with bipolar disorder who paces quickly around the room while talking to themselves
Correct answer: C
Rationale: The correct answer is C. A client with borderline personality disorder who has committed an assault poses a risk to others and themselves, necessitating temporary emergency admission for safety and further assessment. Choices A, B, and D do not indicate an immediate risk to self or others that would require temporary emergency admission.
4. Which of the following statements regarding the length-based resuscitation tape measure is correct?
- A. The resuscitation tape estimates a child's weight based on his or her height.
- B. It is a reliable tool in children who are less than 5 years of age.
- C. The red end of the tape measure is placed at the top of the child's head.
- D. The tape measure can be used in children who weigh up to 75 pounds.
Correct answer: D
Rationale: The length-based resuscitation tape measure is designed to estimate a child's weight based on their length and can be used for children weighing up to 75 pounds. It is a reliable tool for pediatric weight estimation in emergency situations.
5. A client with heart failure is prescribed furosemide (Lasix). The nurse should monitor the client for which potential electrolyte imbalance?
- A. Hyperkalemia
- B. Hypernatremia
- C. Hypokalemia
- D. Hypocalcemia
Correct answer: C
Rationale: When a client with heart failure is prescribed furosemide, the nurse should monitor for hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss, which increases the risk of hypokalemia. Hypokalemia can have serious implications such as cardiac dysrhythmias. Therefore, it is essential to closely monitor the client's serum potassium levels while on furosemide to prevent complications. Hyperkalemia (Choice A) is incorrect because furosemide leads to potassium loss, not retention. Hypernatremia (Choice B) is not typically associated with furosemide use. Hypocalcemia (Choice D) is not a common electrolyte imbalance caused by furosemide.
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